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Research roundup: November 2023 edition

Pain management during procedural abortion, serum etonogestrel levels not associated with mood changes during implant use, and clinical considerations when patients are traveling for abortion care.

by Colleen Denny, MD and Emma Gilmore, MD

published 11/30/23

1. Effects of aromatherapy on patient satisfaction with procedural abortion at less than 10 weeks’ gestation: A randomized controlled trial

Patient satisfaction with pain management and anesthesia during abortion care is an important part of the patient experience, and the experience of pain during procedural abortion is a complex interaction between individual patient factors as well as contextual factors. While much research has investigated different pharmaceutical modalities for improving patients’ experience of pain, relatively less research has examined the use of adjunctive alternative and complementary medicine to improve patient experience. In this randomized placebo-controlled trial including 112 patients, researchers analyzed whether the use of lavender aromatherapy improved different aspects of the patient experience during procedural abortion without IV sedation up to 10 weeks’ gestation. While the authors found no differences between groups in terms of reported pain scores or overall patient satisfaction, they did note that the aromatherapy group was significantly more likely to report finding inhaling the lavender oil helpful and to report they would recommend it to a friend. The authors conclude that this low-risk intervention may be a useful adjunct to patients undergoing procedural abortion without higher levels of sedation.

2.Helping patients choose between pain control options for outpatient procedural abortion at less than 12 weeks gestation

Determining the best pain management regimen for a given patient during procedural abortion can be a difficult process, given the complex physical and psychological aspects of experiencing pain. The majority of first-trimester procedural abortions in the US use either local anesthesia or local anesthesia with moderate IV sedation, but both patients and providers may struggle with choosing a regimen that will maximize their satisfaction with the experience. In this prospective control study, the authors developed an instrument to try to predict patient satisfaction with pain control regimens during procedural abortion through 12 weeks’ gestation among patients choosing either local anesthesia only or local anesthesia with IV moderate sedation. In analyzing data from 149 patients, the researchers determined that while reported patient satisfaction was overall higher in the moderate sedation group (91% vs 66% in the local anesthesia group), only self-reported fear of a minor medical procedure was significantly predictive of decreased satisfaction in the local anesthesia group. Other variables, such as age, gestational age, anticipated pain, self-reported pain tolerance or anxiety, or history of previous deliveries or abortions were not predictive of satisfaction levels. The authors conclude that definitive predictors of patient satisfaction with local anesthesia remain elusive, and that providers should strive to provide evidence-based care and center individual patients’ preferences regarding pain regimens.

3. Travel for abortion care: implications for clinical practice

Abortion care is extremely common in the US, with 930,000 abortions occurring in the US every year and approximately 1 in 4 pregnancies ending in abortion. Patients in the US may face many barriers to accessing abortion care, including a recent increase in state-level restrictions or complete bans that force patients to travel for care. Providers who see patients traveling for abortion care must consider unique logistical challenges that may affect care models and clinical workflow. In this review, the authors discuss several aspects of caring for patients traveling for abortion care. For providers working in restrictive areas, the authors discuss the potential utility in determining gestational age and reviewing medical comorbidities before patients travel, so as to ensure they match the criteria of the receiving institution. The authors also discuss maximizing the safe use of telehealth whenever possible for abortion care, same-day provision of contraception care, avoiding routine follow-up visits after procedural abortion, and offering alternatives to in-person follow-up for medication abortion. The authors generally emphasize the importance of identifying local community resources in restrictive areas, such as funding and support resources as well as local providers that can provide safe and appropriate follow-up care for returning abortion patients as needed.

4. An exploratory study on the possible association of serum etonogestrel concentrations with mood concerns and symptoms among contraceptive implant users

Etonogestrel (ENG) implants provide a highly-effective, long-acting form of contraception and are increasing in popularity among reproductive-aged patients. However, while some patients using the implant report mood changes, it is unclear whether these changes are actually driven by pharmacokinetic variability among patients. In this exploratory study of 900 ENG implant users, the researchers compared a one-time serum ENG level with patients’ self-reported retrospective mood changes. While the authors found that approximately a third of respondents reported mood changes, serum ENG levels were not associated with these changes and did not explain inter-individual variability in mood-related side effects. The authors encourage future research looking at individual patient factors to predict which ENG implant users may be most likely to have mood symptoms.

5. Continuation rates of hormonal intrauterine devices in adolescents and young adults when placed for contraceptive and non-contraceptive indications

Levonorgestrel (LNG) IUDs are frequently used for both highly-effective birth control and menstrual suppression and are safe to place for adolescents whether or not they are sexually active. However, younger patients may have lower continuation rates for IUDs and there is a lack of data on factors that influence these decisions, particularly for individuals who choose IUDs for non-contraceptive reasons. The authors of this study performed a secondary analysis of adolescent-focused data in order to better understand continuation rates for LNG-IUD in adolescent medicine patients. They reviewed 838 completed IUD insertions in adolescents and young adults, of which 44% were for contraception only, and the remainder were for management of menstruation or for both indications. Continuation rates were high at one year for all indications at 77%, but at three years, rates were highest for adolescents who chose the LNG-IUD for non-contraceptive reasons. Adverse events, such as failure to place IUD, malposition, or expulsion, were rare in this population. Overall this data suggests that one year continuation rates are high for all LNG-IUD users within the adolescent and young adult population, and individuals who choose this IUD for menstrual suppression may consistently continue its use for even longer intervals. This information can be used when counseling and treating this age group.

6. At-Home Self-Collection of Urine or Vaginal Samples for Gonorrhea and Chlamydia Screening Among Young People Who Were Assigned Female at Birth

Rates of sexually transmitted infections (STIs) such as gonorrhea and chlamydia are on the rise in the United States, and delays in detection can lead to serious outcomes, including ectopic pregnancy, pelvic inflammatory disease, and infertility. Marginalized groups, such as unstably housed, uninsured, or gender-diverse individuals may experience additional delays in diagnosis due to difficulties in health care access and/or stigma. However, self-collected STI testing may be a solution to some of these barriers, as it is both less costly and less invasive than clinic-based testing. The authors of this paper performed a cross-sectional study to evaluate testing preferences for individuals assigned female at birth, with a secondary objective of evaluating whether certain factors, such as sexual identity, employment, insurance status, or educational attainment affected these preferences. Among 88 participants, the majority preferred at-home testing without any significance based on age or sexual identity. However, individuals with lower educational attainment, unemployment, or lack of insurance expressed a preference for clinic-based testing. Overall, at-home STI testing may be a welcome option for many patients and could increase the rate of diagnosis, thereby allowing for speedier treatment. However, despite the small sample size of this study, these results indicate that social determinants of health may have an effect on individuals’ willingness to engage in at-home testing and this should be further explored.

7. Characteristics of Menstrual Suppression and Its Association With Mental Health in Transgender Adolescents

Transgender and gender-diverse (TGD) adolescents often experience gender dysphoria with the development of secondary sex characteristics, and this can be worsened by menstruation. Menstrual suppression, which is also used in the general population for individuals with heavy menstrual bleeding or cramping, may be helpful for TGD adolescents who continue to have periods, even for those who may be taking testosterone. While this is a widely acknowledged practice, little is known about TGD adolescents’ satisfaction with menstrual suppression and which pharmacologic options are most widely used. The authors of this study investigated this practice through a cross-sectional study at a referral clinic for TGD adolescents, including a total of 530 patients. A quarter of these adolescents were undergoing menstrual suppression, most often with combined oral contraceptive pills. Participants noted high levels of effectiveness and satisfaction from this regimen. The authors found high levels of interest in menstrual suppression from TGD adolescents who were not already undergoing this treatment. However, menstrual suppression did not appear to change gender dysphoria, which this population experienced at high rates, or mood symptoms. More study is needed to evaluate whether the practice improves that aspect of care for TGD adolescents.

8. Depot medroxyprogesterone acetate and breast cancer: a systematic review

Injectable progestin-only birth control, typically depot medroxyprogesterone acetate (DMPA), is used throughout the world and in especially high numbers in sub-Saharan Africa and Southeast Asia. Pre-existing, often controversial research on breast cancer and birth control is available, but there is limited information regarding DMPA users and breast cancer risk. The authors of this study performed a systematic review to focus on this specific question. Almost four thousand studies were evaluated, and 10 articles (mostly case-control studies) were reviewed in depth. The majority of results did not find an increased risk of breast cancer with DMPA use, and length of DMPA use was not associated with increased risk. A smaller subset of studies found a possible increased risk in current or recent users, but sample sizes were small, the methodology may have been flawed, and it is difficult to make generalizations based on this data. Overall, DMPA continues to be a safe and effective method of birth control.

Colleen Denny, MD, is an attending ObGyn at Bellevue Hospital in New York City, where she is the Medical Director of the Women's Clinic, and a clinical assistant professor with the NYU School of Medicine. She enjoys providing care for patients in all phases of life and is especially interested in issues related to contraception access and public health. Outside of work, she’s a runner, a dancer, and a bit of a crossword puzzle nerd.
Emma Gilmore is a fellow in Complex Family Planning at the University of Pennsylvania. She completed her residency in Obstetrics and Gynecology at New York University. She's passionate about reproductive rights, medical education, and combating health care disparities, particularly in sexual and reproductive health. In her free time, she can be found taking her dog on walks around the beautiful parks in and around Philadelphia.
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